Transmetatarsal (partial foot) amputation with well-healed incision. Somewhat unstable ankle or requiring better toe lever at push off phase of gait.
This single-patient case study exemplifies the value of an amputation prevention program. A 74-year-old man presented for evaluation of a nonhealing stump wound. Six years earlier, he was seen at an outside institution with a 1-week history of left foot redness and pain. At that time, the patient was noted to have decreased range of motion of the left foot, with erythema extending to the ankle. The patient denied any previous history of rest pain, intermittent claudication, or trauma, and his medical and surgical histories were nonsignificant. He did not have a primary care physician and had not been seen by a physician in the recent past.
A Syme amputation was named for James syme, a noted University of Edinburg surgeon, in the mid-1800s. This amputation is an ankle disarticulation in which the heel pad is kept for good weight bearing. The Syme amputation results in a residual limb that possesses good function due to the long lever arm to control the prosthesis and the ability to ambulate without the prosthesis.
The level of tibial transaction should be as long as possible between the tibial tubercle and the junction of the middle and distal thirds of the tibia. A long posterior flap for transtibial amputations is advantageous because it is well vascularized and provides an excellent weight-bearing surface. In addition, the scar is on the anterior border, an area that is subject to less weight bearing. The deep calf musculature is often thinned to reduce the bulk of the posterior flap.
Bulb makes the socket self suspending Disadvantages - cosmetically poor because stump is very wide - many women unhappy with cosmesis Indication - for non-healing heel ulcers associated with vascular insufficiency - not so severe that wound won't heal Technique - ulcer excised & longitudinal incision proximal & distal - T Achilles reflected - all of posterior process of calcaneum excised - this makes skin closure easy - T Achilles can't be reattached & is left free - patient must wear rigid AFO style partial foot prosthesis with cushion heel long term Long posterior flap now standard - previously always 6 inches from knee joint but trend now is to make as long as possible - avoid distal 1/3 as poor soft tissue coverage & padding Posterior flap length is equal to diameter of limb at level of bone cut plus 1cm - fibula is cut 1-2cm shorter - don't perform tibiofibular synostosis - usually get painful non-union - gastrocnemius myodesis
The STAMP Amputation Prevention Program is a team that was compiled and led by a physician who championed this approach. Essential members of the team are each specially trained to screen, triage, and treat patients with CLI. Team members include an endovascular specialist, noninvasive imaging specialist, midlevel provider, registered nurse, vascular technicians, medical assistant, schedulers, cardiovascular laboratory interventional team, and clinical research staff. The team also includes a dedicated Peripheral Vascular Coordinator (registered nurse position) whose responsibilities include policy and procedure development, the organization of educational and screening events, facilitation of out-of-area referrals, and coordination of communication between members of the multidisciplinary team.
Diagnostic examination revealed left foot cellulitis. He underwent irrigation and debridement in an attempt to decompress the inflamed region. The patient was also noted to have hypertension and hyperglycemia, and appropriate medical management was initiated. The patient’s clinical course continued to deteriorate with the development of persistent fevers and further progression of left foot edema. He was diagnosed with possible osteomyelitis of his second, third, and fourth metatarsals by both bone scan and magnetic resonance imaging. Extensive necrosis developed. After infectious disease and vascular surgery consultations, the patient was taken for a guillotine amputation. On the second postoperative day, the patient returned to the operating room for debridement and wound closure.
Due to his deconditioning and multiple complex diagnoses, the patient was discharged to a long-term assisted-care facility. Two weeks later, the transmetatarsal amputation site became necrotic, and the patient underwent below-the-knee amputation. The patient did not undergo angiography at any time before his amputations. Upon presentation to Metro Health Hospital, the patient’s medical history was significant for type II diabetes, hypertension, congestive heart failure, dyslipidemia, acute renal insufficiency, and peripheral vascular disease. The patient initially presented to the wound clinic for evaluation of a small, nonhealing ulcer on his left stump. The patient reported intermittent wounds over the course of 6 years due to rubbing of his prosthesis. In addition to the ulcer on the patient’s left stump, he reported a 1-week history of rest pain in his right toes and diffuse erythema of the anterior aspect of his right lower extremity. The erythema was deemed unlikely to be ischemic in nature. An x-ray was performed, revealing gas in the soft tissues, which is suggestive of cellulitis or ulceration. No radiographic evidence of osteomyelitis was noted. The patient began undergoing serial debridement therapy with ongoing wound assessment.